Healthcare Provider Details

I. General information

NPI: 1659591279
Provider Name (Legal Business Name): MERRICK BUCKINGHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 DR MARTIN LUTHER KING JR AVE NE
ALBUQUERQUE NM
87106-4713
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-6000
  • Fax: 505-925-7849
Mailing address:
  • Phone: 505-272-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number18180
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2010-0054
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: